<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket>
<wicket:extend>
    <h1 class="pageTitle">
        <wicket:message key="titel"/>
    </h1>
    <form class="form-horizontal" wicket:id="form">
        <fieldset>
            <div class="row-fluid">
                <div class="span6">
                    <div class="control-group print">
                        <label class="control-label">
                            Verrichtingsdatum t/m
                        </label>
                        <div class="controls">
                            <div class="input-append date">
                                <input wicket:id="verrichtingsdatumTotEnMet" type="text" placeholder="dd-mm-jaar"
                                       size="16" class="input-small three-months">
                                <a href="javascript:void(0);" class="btn"
                                   onclick="$(this).prev().datepicker('show');return false;" title="Datum"><i
                                        class="icon-calendar"></i></a>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="span6">
                    <div class="control-group print">
                        <label class="control-label">
                            Betalingen huisarts
                        </label>
                        <div class="controls">
                            <input type="checkbox" wicket:id="verrichtingenHuisarts"/>
                        </div>
                    </div>
                    <div class="control-group print">
                        <label class="control-label">
                            Betalingen BMHK-laboratorium
                        </label>
                        <div class="controls">
                            <input type="checkbox" wicket:id="verrichtingenLaboratorium"/>
                        </div>
                    </div>
                </div>
            </div>
            <div class="row-fluid">
                <div class="span12">
                    <div class="form-actions clearfix">
                        <button class="btn btn-primary" wicket:id="betalen"><i class="icon-list-alt icon-white"></i>
                            Betalen
                        </button>
                    </div>
                </div>
            </div>
        </fieldset>
    </form>

</wicket:extend>
</html>
